Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.     

Pregnancy outcome and deliveries following laparoscopic myomectomy

Uterine rupture after myomectomy by laparotomy is not a common occurrence. Some case reports of uterine rupture after laparoscopic myomectomy (LM) raise the question of the quality of the uterine scar produced when this technique is performed. In order to assess the outcome of pregnancies and deliveries after LM and to assess the risk of uterine rupture, we performed an observational study. Questionnaires were mailed to all women who had had LM for at least one intramural or subserosal myoma of more than 20 mm diameter and who were aged <45 years. Ninety-eight patients became pregnant at least once after LM, giving a total of 145 pregnancies. Among the 100 patients who had delivery, there were three cases of spontaneous uterine rupture. Because only one of these uterine ruptures occurred on the LM scar, the risk of uterine rupture was 1.0% (95% CI 0.0-5. 5%). Seventy-two patients (72.0%) had trials of labour. Of these, 58 (80.6%) were delivered vaginally. There was no uterine rupture during the trials of labour. Spontaneous uterine rupture seems to be rare after LM. This risk should not deter the use of LM if needed. When performing LM, particular care must be given to the uterine closure.     

Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy

Laparoscopic myomectomy is still a debated procedure and there are conflicting opinions regarding the recurrence rate. Laparoscopic myomectomy may present a higher risk of recurrence compared with abdominal myomectomy. The aim of this investigation was to analyse the recurrence rate of myomas after surgery. From January 1991 to June 1998, 165 myomectomies were performed for symptomatic myomas measuring at least 3 cm in diameter and numbering seven or less per patient. During the first 3 years of this survey, 81 patients were randomized for abdominal or laparoscopic myomectomy. Transvaginal ultrasound examination was performed within 15-30 days of surgery and every 6 months for a post-operative period of 40 months. The two groups had similar pre-operative clinical features and the number and volume of myomas did not differ between the two groups. At the end of the study the group of abdominal myomectomies showed nine recurrences (23%) against 11 (27%) of the laparoscopic group. In order to evaluate the recurrence rate in relation to several risk factors, laparoscopic myomectomies were performed from 1991 in 84 patients who agreed to follow-up (and were not in the randomized group). Of these, 78 patients were evaluated with transvaginal ultrasound for a mean interval of 26 months and 17 (21.78%) recurrences were found. Most recurrences (75%) were seen at ultrasound between 10 and 30 months after surgery. The patient's age, pre- and post-operative gravidity and parity had no influence on recurrence. Neither the number of myomas removed nor the depth of penetration or size were positively associated with the risk of recurrence. However, an associated risk factor was pre-operative gonadotrophin-releasing hormone agonist treatment (P < 0.02). None of the women with recurrence required additional surgery. We conclude that laparoscopic myomectomy is a reliable procedure. The recurrence rate is similar to that seen after abdominal myomectomy.     

Laparoscopic myomectomy in premenopausal women with and without preoperative treatment using gonadotrophin-releasing hormone analogues.

The present study was undertaken in order to evaluate the usefulness or otherwise of preoperative gonadotrophin-releasing hormone (GnRH) analogue treatment prior to laparoscopic myomectomy. From June 1993 through December 1996, 60 premenopausal women aged between 25 and 42 years and with a sonographic diagnosis of intramural or subserous myomas were selected for laparoscopic myomectomy at the Department of Obstetrics and Gynaecology of the Catholic University of The Sacred Heart, Rome. According to a computer-generated sequence, 30 patients were submitted to three cycles of GnRH analogue treatment prior to surgery, whereas no preoperative treatment was prescribed to the other 30 patients. Laparoscopic myomectomy was successfully performed in all patients for a total of 174 myomas excised laparoscopically. The patients' mean age, the number of myomas per patient, the mean diameter of the myomas, parity and estimated blood loss were similar in both groups. The operative time was significantly longer in the group of patients submitted to GnRH analogue treatment than that of the group of patients not submitted to any preoperative medical therapy (157.5 +/- 74.71 versus 112.33 +/- 54.71 min; P = 0.01). No intra-operative complications occurred. In no case was blood transfusion necessary. Two patients developed post-operative fever (temperature > 38 degrees C.). The mean length of hospital stay was 2.39 days and was similar in both groups. Thirteen spontaneous pregnancies occurred among 24 infertile patients (54.1%). The pregnancy rate for these patients was similar in both groups. The viable term delivery rate was 45.8%. The authors conclude that laparoscopic myomectomy is a feasible and safe procedure. The post-operative pregnancy rate for infertile patients is similar to that following laparotomic myomectomy. The present study suggests that preoperative GnRH analogue treatment does not offer any significant advantages for laparoscopic myomectomy.     

腹腔镜下子宫肌瘤剔除术的临床应用

目的探讨腹腔镜下子宫肌瘤剔除术的手术技巧、复发及术后妊娠情况。方法子宫肌瘤患者217例，年龄25～43岁，平均年龄32岁（标准差7．3岁）．其中有蒂浆膜下肌瘤37例．阔韧带肌瘤4例．宫颈肌瘤7例，肌壁间肌瘤及无蒂浆膜下肌瘤169例．行腹腔镜下子宫肌瘤剔除术（laparoscopic myomectomv．LM）。结果217例手术均获成功．无严重并发症．217例中13例失访．204例随访11～47个月，平均（29．00±10．32）个月。术后9～47个月复发71例．占34．80％．有生育要求者49例，妊娠率46．67％．21例（21次）妊娠中．1例流产．1例异位妊娠．1例妊娠高血压疾病早产（剖宫产）．9例足月妊娠，其中7例行剖宫产，2例顺产；9例继续妊娠中[平均（22．00±6．82）周]，无一例子宫切口瘢痕裂开。结论LM后可提高妊娠率，复发率同开腹手术。LM后妊娠是安全的．但剖宫产几率增加。LM具有创伤小、恢复快的优点．是一种安全、可靠的手术方法．     

Fertility after laparoscopic myomectomy: preliminary results

We report the limits, complications, subsequent fertility and outcome of pregnancies after laparoscopic myomectomy. From January 1990 to October 1995, 143 patients underwent a first laparoscopic approach to myomectomy. A total of 41 patients (28.7%) had a laparoconversion (12 cases for a number of myomata >5, 15 cases for myoma diameter >7 cm, 12 cases for peroperative haemorrhage and two cases for adenomyosis). Seventy patients (49%) wished to conceive: 26 had undergone laparoconversion and 44 laparoscopic myomectomy. A total of 19 pregnancies were obtained in 17 patients after laparoscopic myomectomy (38.6%): eight vaginal deliveries, three Caesarean sections, four miscarriages, two abortions, one ectopic pregnancy and one therapeutic abortion. The pregnancy rate in patients with unexplained infertility and with multifactorial infertility was 48.2% and 20% respectively. The mean delay to conception was 11.3 months. No uterine rupture was noted. Pelvic adhesions were found in the four patients who underwent second- look procedure. Our preliminary results indicate that laparoscopic myomectomy is a useful technique.      

Endoscopic management of uterine myoma

This study was undertaken to evaluate the various gynecologic endoscopic surgical techniques including resectoscopic myomectomy, laparoscopic myomectomy, and laparoscopy assisted vaginal hysterectomy (LAVH) used in the treatment of uterine myomas. The medical records of 136 cases of uterine myomas treated using one or more of the gynecologic endoscopic surgical techniques in the Department of Obstetrics and Gynecology at Yonsei University were retrospectively reviewed from March 1997 to September 1998. Of the 136 cases reviewed, there were 40 submucosal myomas and 96 intramural and subserosal myomas. For statistical analysis, Student's t-test was used. Submucosal myomectomy using the resectosope was performed in 35 cases (mean age: 39 +/- 1.5 years), laparoscopic myomecotmy in 35 cases (mean age: 36 +/- 1.9 years), and LAVH in 66 cases (mean age: 42 +/- 1.1 years). In cases of huge myomas, the GnRH agonist was used prior to surgery, and in cases of heavy uterine bleeding, angioblock of the uterine artery was undertaken before the endoscopic procedures. The mean operating time was significantly shorter in resectoscopic myomectomy (41 +/- 12 min), followed by laparoscopic myomectomy (85.0 +/- 10.3 min) and LAVH (123 +/- 5.3 min). The mean hospital stay for resectoscopic myomectomy, laparoscopic myomectomy, and LAVH was 1.9 +/- 0.5, 2.5 +/- 0.5, and 3.4 +/- 0.8 days (p < 0.001), respectively. There were 3 cases of complications including pulmonary edema and uterine perforation in the resectoscopic myomectomy group, and 4 cases of complications including bladder, ureter, and epigastric vessel injury in the LAVH group. In conclusion, the therapeutic effect of various gynecologic endoscopic surgical techniques can be maximized in terms of shorter operation time, shorter hospital stay, faster recovery, and less blood loss by the appropriate management of uterine myoma in well-chosen patients.     

Treatment of uterine leiomyomas with luteinizing hormone-releasing hormone antagonist Cetrorelix

The efficacy of the luteinizing hormone-releasing hormone antagonist Cetrorelix (SB-75) in the medical management of uterine leiomyomas (fibromas) was evaluated. Cetrorelix was administered to 18 pre- menopausal women with myomas with a mean age of 33.3 years, who had been candidates for hysterectomy. The initial dose of Cetrorelix was 5 mg twice daily s.c. for the first 2 days and thereafter 0.8 mg was given twice daily s.c. for at least 3 months. The mean duration of the treatment was 4.4 months. Before the therapy with Cetrorelix, the mean uterine volume, measured by ultrasonography, was 395.4 +/- 69.2 ml (range 89-1166). Sixteen patients showed a progressive reduction in uterine volume from 410.4 +/- 77.1 to a mean of 230.8 +/- 52.6 ml at 3 months. All patients became amenorrhoeic and had hot flushes. After treatment with Cetrorelix, a surgical myomectomy was performed in 12 women. One of the patients subjected to myomectomy after therapy with Cetrorelix became pregnant. These patients have been followed for up to 25 months and only in one case has the uterine volume increased after therapy. Three patients had good responses to therapy with Cetrorelix and it was decided to follow them only by observation. One patient became pregnant 2 months later. In the other patient, the uterine volume remained unchanged for the duration of the follow-up of 2 years and the third patient showed an increase after 21 months. In three patients, it was necessary to perform total hysterectomy. In 14 patients, serum concentrations of luteinizing hormone, follicle stimulating hormone and oestradiol decreased after the administration of the first dose of Cetrorelix and continued at subnormal values throughout therapy. In 15 patients who were not subjected to total hysterectomy, menstrual function returned at 1 month after cessation of treatment. Overall results support the use of Cetrorelix for the management of uterine leiomyomas.      

Laparoscopic myomectomy: indications, surgical technique and complications

The indications and complications of laparoscopic myomectomy were evaluated with regard to its limitations, benefits and feasibility. Surgical technique with related difficulty was also reported. From a population of 89 patients, a total of 104 myomas were removed laparoscopically. A retrospective study was carried out of 54 patients with myomas >3 cm. Indications for surgery were pain or abnormal bleeding (37%), increase in size of the myoma in infertile patients (48.1%) and infertility requiring assisted reproductive technology (14.9%). A total of 57 myomas >3 cm were removed from these patients. The number of myomas per patient varied from 1 to 4. The myomas were intramural (n = 34), subserosal (n = 19) and submucosal (n = 4). The size of the dominant myoma ranged from 3-8 cm (mean 4.16). In all cases the uterine wall was sutured either in one (n = 42) or two planes (n = 15) depending on the depth of the myometrial defect. The laparotomy conversion rate was 1.8% (n = 1); mean blood loss was 84 ml; average hospital stay was 2.09 days and the overall complication rate was 1.8%. Five patients went on to conceive; the pregnancy was uneventful and proceeded to Caesarean section at 38 weeks. No adhesions at myomectomy sites were observed in these patients. At 6 months follow-up, 18 out of 20 patients with pain or haemorrhagic disorders prior to surgery showed remission of their complaints. Our study confirms the feasibility of laparoscopic myomectomy as a technique leading to a low complication rate and remission of symptoms. At the present time, statistically significant data concerning post-surgical adhesion formation or pregnancy outcome are not available.      

Pregnancy following treatment of symptomatic myomas with laparoscopic bipolar coagulation of uterine vessels

BACKGROUND: Laparoscopic bipolar coagulation of uterine vessels (LBCUV) has been employed for women with symptomatic uterine myomas, but its effect on subsequent pregnancy has not been characterized. METHODS: Four-hundred and twenty-three women entered the study between March 1999 and December 2001. Of these, 142 women (33.6%) were under the age of 40 years at the time of LBCUV, 36 of whom (36/142, 25.3%) were sexually active without contraception. In a prospective study of 142 patients (<40 years old) undergoing LBCUV for symptomatic myomas, 15 women became pregnant (17 total pregnancies) and were evaluated by physical and ultrasound examinations. RESULTS: The volume of the dominant myoma was 117.4 +/- 118.4 and 36.8 +/- 56.8 cm(3) before and after LBCUV respectively. Volume of the dominant myoma after pregnancy was 46.2 +/- 76.7 cm(3) (mean +/- SD). There was a significant difference in myoma volume before and after LBCUV (P = 0.002), but no significant difference in myoma volume when comparing post-partum size with post-LBCUV size (P = 0.269). Pregnancy outcomes included seven miscarriages in the first trimester and one premature rupture of membrane (PPROM). Although the other pregnancies were regarded as uncomplicated, only two women were delivered of normal neonates as the other seven pregnancies were terminated secondary to patient request. CONCLUSIONS: The pregnancy and term pregnancy rates in sexually active women without contraception were 41.6% (15/36) and 5.6% (2/36) respectively. Because a relatively high rate (7/17, 41.2%) of early miscarriages was observed, we recommend that this procedure be employed only for women who do not desire additional children.     

Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynaecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study

BACKGROUND: Following myomectomy, postoperative adhesions occur in many patients with adverse effects on fertility. This study investigated the applicability, safety and efficacy of an auto-crosslinked hyaluronan gel in preventing adhesion formation after laparoscopic myomectomy. METHODS: Fifty-two patients aged 22-42 years, undergoing surgery at four centres, were randomly allocated to receive either the gel or no adhesion prevention. The incidence and severity of postoperative adhesions were assessed laparoscopically after 12-14 weeks in a blinded, scored fashion. The primary efficacy variable was the presence/absence of postoperative adhesions at second-look. RESULTS: A nonsignificantly higher proportion of patients receiving the gel were free from adhesions (13 of 21; 62%) compared with control patients (9 of 22; 41%), with a statistically significant difference between the severity of uterine adhesions at baseline and at second-look (0.3 +/- 0.9 versus 0.8 +/- 1.0, P < 0.05). In subjects undergoing myomectomy without concomitant surgery, the proportion of adhesion-free patients was 8 of 12 (67%) and 4 of 11 (36%) (not significant) in the gel and control groups, respectively, with a significant difference in the mean severity scores (P < 0.05). In subjects without uterine adhesions before myomectomy, 12 of 18 (67%) and 8 of 20 (40%) patients in the gel and control groups, respectively were adhesion-free (not significant), with a significant difference in the severity of uterine adhesions (P = 0.05). CONCLUSIONS: Our results suggest that the auto-crosslinked hyaluronan gel may have a favourable safety profile and efficacious antiadhesive action following laparoscopic myomectomy.     

剖宫产同时子宫肌瘤剔除35例临床研究

目的 探讨妊娠合并子宫肌瘤病人在剖宫产同时肌瘤剔除术的可行性，安全性。方法 妊娠合并子宫肌瘤35例，在剖宫产同时行肌瘤剔除术，与35例单纯剖宫产的产妇做对照。结果 手术时间，术后出血量，术后病率，术后住院天数，肌瘤剔除组与单纯剖宫产组比较，差异不显著（均P〉0．05）。结论 剖宫产同时行肌瘤剔除术是可行的，安全的。妊娠合并子宫肌瘤时，应放宽剖宫产指征，同时行子宫肌瘤剔除术。     

Ureteral complications from laparoscopic hysterectomy indicated for benign uterine pathologies: a 13-year experience in a continuous series of 1300 patients

BACKGROUND: The aim of this study was to evaluate the risk of ureteral injuries and to discuss how to avoid their occurence after laparoscopic hysterectomy indicated for benign uterine pathologies. METHODS: This observational study covers the period from January 1993 to December 2005 (retrospective study from 1993 to 2000 and prospective from 2001). We reviewed incidence, methods of diagnosis and management of ureteral injuries. RESULTS: The rate of ureteral injuries was 0.3% (four patients). Three patients presented a ureteral fistula diagnosed secondarily some time after the operation. The fourth patient presented a ureteral injury that was diagnosed peroperatively. Three out of four of the lesions were observed on the right side. In every case, there were preoperative risk factors connected with a past history of surgery, or the lateral location of uterine myomas. All four patients needed ureterovesical reimplantation. The outcome was good in all four cases. CONCLUSIONS: The rate of ureter complications after laparoscopic hysterectomy is low and comparable to that observed after hysterectomy by laparotomy. The risk should not prevent laparoscopic hysterectomy being used more widely. Prevention depends on training in the technique and the surgeon's experience.     

Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study

BACKGROUND: This prospective study was designed to evaluate the operative morbidity and reproductive outcome in patients who had secondary myomectomy for recurrent symptomatic uterine fibroids. METHODS: A total of 58 women were subjected to a secondary myomectomy via the abdominal route. The operative morbidity such as blood loss, presence of adhesions and febrile index were estimated and the pregnancy outcome over a 2-4 year period of follow-up. RESULTS: The mean age and standard deviation (+/- SD) of the women was 35 (+/- 2.4) years. Nineteen patients (33%) had a postoperative temperature vertical line 100 degrees F and the estimated blood loss ranged from 159-2500 ml (median 700 ml). Seven patients (12%) required blood transfusion and one had a hysterectomy due to haemorrhage. Nine women (15.5%) became pregnant but only five (56%) had live births. Those with successful pregnancies tended to be younger with a mean age of 31.8 (+/- 2.6) years versus 35 (+/- 1.8) years, (P = 0.08, non-significant) and had fewer uterine leiomyomata; median with range values, 2 (1-6) versus 7 (6-15). The variables which best predicted the postoperative likelihood of pregnancy were; age, presence of tubal adhesions and the number of uterine fibroids. CONCLUSION: This prospective study showed a high operative morbidity and a poor fertility outcome after a repeat myomectomy. The factors affecting successful outcome in a logistic regression model were age, tubal adhesions and number of uterine fibroids.     

Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier

To evaluate the effectiveness of the oxidized regenerated celluloseabsorbable barrier (Interceed®, TC7) in the prevention ofde-novo adhesion formation after laparoscopic myomectomy, aprospective and randomized study was performed at the Departmentof Obstetrics and Gynaecology of the University of Cagliari,Cagliari, Italy. A total of 50 pre-menopausal non-pregnant women,aged 23—42 years, who submitted to laparoscopic myomectomyfrom January 1993 to June 1994, were randomized to surgery alone(control group, n = 25) or surgery and oxidized regeneratedcellulose barrier (Interceed group, n = 25). Neither group receivedany other treatment for adhesion prevention. A second-look laparoscopywas performed 12—14 weeks after laparoscopic myomectomy.The incidence of adhesion-free patients was assessed at second-looklaparoscopy by an investigator not informed of the treatment.The numbers of adhesion-free patients were three out of 25 (12%)in the control group and 15 out of 25 (60%) in the treatmentgroup (P < 0.05). In conclusion, the oxidized regeneratedcellulose absorbable barrier significantly reduced de-novo adhesionformation after laparoscopic myomectomy.     

Effects of 3 month therapy with danazol after laparoscopic surgery for stage III/IV endometriosis: a randomized study.

The effect of treatment with danazol was evaluated with respect to expectant management after laparoscopic conservative surgery. All patients conservatively operated at laparoscopy for stage III-IV endometriosis from July 1994 to October 1996 were requested to enter the study. Patients who underwent surgery for recurrent endometriosis were excluded from the study, as well as patients who had taken hormonal therapies before laparoscopy. Informed consent was obtained from 77 women who were randomized after surgery to treatment with danazol 600 mg daily for 3 months (n = 36) or to expectant management (n = 41). All patients were regularly followed up every 6 months for evaluation of fertility, recurrence of pain symptoms and disease. During the follow-up, six (55%) of the 11 infertile women allocated to danazol and eight (50%) of the 16 given no treatment became pregnant (not significant). Moderate/severe pelvic pain recurred during follow-up in seven (23%) of the 31 women with pelvic pain allocated to the danazol group and nine (31%) of the 29 allocated to no treatment; the respective cumulative pain recurrence rates at 12 months were 26 and 34% (log rank test, not significant). Three women (8.3%) treated with danazol and six (15%) who received no treatment had disease recurrence as demonstrated by gynaecological examination and/or pelvic ultrasonography (not significant). Our results do not demonstrate a significant advantage of 3 month danazol therapy after laparoscopic surgery for stage III-IV endometriosis with respect to postoperative expectant management.     

Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure

BACKGROUND: To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure. METHODS: This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy. RESULTS: Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies. CONCLUSIONS: Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.     

Successful myomectomy during pregnancy

BACKGROUND: Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented. METHODS: A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms. RESULTS: Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications. CONCLUSIONS: These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.     

Fertility outcomes following myomectomy in an urban hospital setting

OBJECTIVE: Infertility is rarely a consequence of myomas. However, a causal relationship may be suspected when other causes of infertility have been excluded. Uterine myomas have been reported in 27% of infertile women; 50% of women with unexplained infertility become pregnant after myomectomy. The objective of this study was to establish the impact of the surgical removal of myomas on fertility outcomes in women experiencing recurrent pregnancy loss or unexplained infertility. Fallopian tube, anovulatory disorders and male fertility factors had been appropriately excluded. DESIGN: This was a retrospective study in which we compiled data from the medical records of eight patients from 2003-2004 who underwent abdominal myomectomy for infertility or recurrent pregnancy loss. We calculated rates for subsequent spontaneous abortion, preterm delivery, cesarean delivery, malpresentation and postpartum hemorrhage. RESULTS: There were two patients who were nulliparous premyomectomy, and six had recurrent pregnancy losses. There was a cumulative success rate of 75% (six live births in eight patients) following myomectomy. One had two subsequent pregnancies. There were no spontaneous abortions. Three (37.5%) patients failed to conceive postmyomectomy, one of which was found to have bilateral tubal occlusion. Of the six pregnancies achieved, two (33%, 95% CI 2.06, 3.14) were preterm deliveries, six (100%, 95% CI 1.74, 3.50) were delivered by cesarean section and three (50%, 95% CI 3.50, 1.73) were malpresentations (two breech, one transverse lie). One patient (16%, 95% CI 2.06, 3.30) had abruptio placentae and two patients (33%, 95% CI 2.06, 3.14) experienced postpartum hemorrhage. CONCLUSION: This study suggests that there may be a beneficial effect of surgical removal of myomas on enhancing fertility and successful pregnancy outcome. However, the sample was too small to achieve statistical significance.     

Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.